Difficulty Going Research Articles

Clinical Reasoning: Childhood-onset atrophy and spasticity

A 46-year-old woman who had been adopted presented with progressive weakness. Motor development had been normal until age 10 years. At that time, she had noted difficulty walking, imbalance, falls, and urinary frequency. By middle school, she had developed weakness and atrophy in her hands. In her mid-30s, she noted progressive bilateral foot drop. She had begun to use a walker 10 years ago. She recently had more trouble going upstairs, with frequent falls. After a fall 1 year ago, she began having sharp pain radiating into both thighs, with numbness and tingling.

Differences between the profiles of institutionalized elderly people and those on waiting lists and who do not want to be institutionalized

Objective To identify the demographic, environmental, economic, functional, and health characteristics and the lifestyle habits of elderly persons considering their degree of institutionalization. Method A cross-sectional observational study was carried out of individuals in long-term care institutions for the elderly (resident group) in João Pessoa in the state of Paraíba, those on the waiting list (waiting list group) for such institutions, and those who did not demonstrate interest in being institutionalized (non-waiting list group). Fifty elderly persons per group were interviewed, paired by sex, age and education level. Results The non-waiting list group had a higher proportion of married individuals (p<0.0001), mean number of children (p=0.0068), number of homeowners (p=0.0060) and less difficulty going out, with a higher frequency of activities. The waiting list group presented a higher proportion of individuals living alone (p=0.0089), and a lower frequency and more difficulty going out. There was no significant difference in the functional capacity of the three groups (p=0.2019). Conclusion There were differences among the three groups; however, the waiting list group had much more similar characteristics to the resident group than the non-waiting list group. Elderly persons on waiting lists to be institutionalized represent a neglected social group both in terms of research and public policies.

The Effect of Perioperative Corticosteroids in Total Hip Arthroplasty: A Prospective Double-Blind Placebo Controlled Pilot Study

BackgroundSurgery produces a rapid rise in interleukin 6 (IL-6) which may increase the risk of deep vein thrombosis and medical complications. Perioperative corticosteroids suppress IL-6 release in patients undergoing total knee arthroplasty. This study evaluates the effects of a perioperative corticosteroid regimen on IL-6 formation, thrombogenesis, fibrinolysis, and clinical outcomes in patients undergoing unilateral, uncemented, total hip arthroplasty. MethodsTwenty-seven patients (14 placebo and 13 study) were enrolled in this randomized, double-blind, placebo-controlled trial. The study group received 20 mg of prednisone orally followed by 2 doses of intravenous hydrocortisone, each 8 hours apart. Blood was drawn at several time points for IL-6, prothrombin fragment 1.2, and plasmin-alpha-2-antiplasmin complex, a marker of fibrinolysis. In-hospital visual analog pain (visual analog scale) scores, patient-controlled analgesia use, and ability to climb stairs were recorded. ResultsMean serum IL-6 levels at 6 and 24 hours postoperatively were significantly lower for the study group, whereas serum prothrombin fragment 1.2 and plasmin-alpha-2-antiplasmin were not statistically different at any study time point. Average pain scores were similar (P > .05), but study group experience less severe pain (P < .01) and less patient-controlled analgesia (P = .02). At 3 months, 4 patients in the placebo and 1 patient in the study group had difficulty going up and down staircases (P = .08). ConclusionThe use of corticosteroids was associated with a statistically significant decrease in IL-6 at 6 and 24 hours postoperatively but did not affect thrombogenic markers. The study group had improved postoperative analgesia and a trend toward improved functional outcome at 3 months postoperatively.

Evaluation of the Effect of Mega MSM on Improving Joint Function in Populations Experiencing Joint Degeneration

Joint degeneration has become a commonplace problem in aging populations. The main clinical manifestations include joint pain, joint stiffness and joint swelling with functional disorder. Mega MSM is a nutritional supplement that may provide potential relief for joint problems associated with joint degeneration. The current experiment performed was a 12-week, randomized, double-blind, controlled study conducted on populations in China experiencing joint degeneration. The objective of the study was to determine whether the daily use of Mega MSM capsules could improve joint function, relieve symptoms of joint degeneration and improve the quality of life in aging populations. A total of 100 male and female participants over 50 years old who had at least one of the related symptoms of joint degeneration (joint pain, joint stiffness, joint swelling, difficulty walking, difficulty getting up from bed and difficulty going down stairs) were recruited and their symptoms of joint degeneration before and after the intervention were recorded. In this study, Mega MSM shows positive effects in improving joint function, relieving symptoms associated with joint degeneration and improving the quality of life in aging populations.

도시철도 환승시설의 안전 및 편의성 향상을 위한 통로 폭 산정에 관한 연구

최근 도시철도 역사 및 환승시설의 이용객 수용을 위한 규모가 미흡하여 극심한 혼잡상황이 반복됨에 따라 이용객의 불편이 증가하고 있으며, 비상상황 발생 시 이용객의 군집이동에 의한 대규모 사고가 예측되고 있다. 이에 환승시설 개선에 가장 효율적인 환승통로 폭에 대하여 개선안을 제시하고자 설계지침의 환승통로 폭 산정식과 보행 서비스 수준(LOS)의 이론적 근거를 검토하고 환승통로 모의실험과 5개 역사 현장조사를 실시하였다. 보행환경 모의실험 결과 LOS E등급은 평균보행속도를 내기 어려우며 충돌을 피하기 위한 움직임이 빈번함을 알 수 있었고, 피난상황인 경우 대규모 참사가 발생할 수 있으므로 환승통로의 LOS는 D등급으로 상향이 필요하다. 또한 LOS D, E등급에서 밀도 값의 범위가 큼으로 인하여 최대 및 최소 밀도로 산정되는 환승통로 폭의 차이가 최대 약 80%로 나타났다. 도출된 결과로부터 설계지침의 통로 폭 산정 시 사용되는 설계요소에 대한 개선안을 제시하였다. Congested situation owing to lack of metro station facility capacity has greatly intensified and repeated recently. Therefore, metro users suffer much inconvenience and large accidents due to the group walking in an emergency scare have been predicted and concerned. To suggest improved calculation method of transfer facilities PW (the width of passageway), the PW formula in the Design Guidelines and the theoretical basis of LOS (Level of Service) are reviewed. Also, the simulation of pedestrian environment and field survey for five stations are conducted. It is observed that LOS E showed the difficulty going to the average walking speed and the movement frequently to avoid the collision from the simulation results, thus LOS E offered by the guidelines needed the upward to LOS D in preparation for a large-scale disaster. It is found that the difference between the widths which is calculated based on the maximum and the minimum density of the same LOS grade is up to about 80% because the range of density values in the LOS D and LOS E is so great. Based on the results, the appropriate design factors used in calculation of the PW are provided.

The role of the built environment and assistive devices for outdoor mobility in later life.

Despite theoretical advances in our conceptualization of disability, the "environment" remains a largely unspecified term in disablement models. The purpose of this research is to draw upon on a unique state-of-the-art nationally representative data set with innovative measures that provide the opportunity to tease apart and specify the role of different environmental factors in the disablement process. Using multinomial logistic regression with data from the first round of the recently launched National Health and Aging Trends Study (N = 6,578 community-dwelling Americans age 65+), this paper examines the role of the built environment (e.g., stairs or ramps leading up to the home) and mobility devices on reported difficulty going outside by oneself. Almost three quarters of community-dwelling older Americans live in a residence that has stairs at the entrance. Older adults who use a walker to help them get around are adversely affected by stairs at the entrance to their home, effectively doubling the odds of reporting difficulty going outside independently. Roughly 10% of community-dwelling older Americans live in a residence with a ramp at the entryway, which reduces the odds of outdoor mobility difficulty threefold among those using wheeled mobility devices. However, ramps at the entryway are associated with a higher likelihood of reporting difficulty going outdoors among those who do not use any type of mobility device. A better understanding of the complexities of the environment in the disablement process is critical for the planning and development of age-friendly environments allowing older adults to age in place.

Memory Constraints on Infant Learning From Picture Books, Television, and Touchscreens

AbstractThe past 15 years have seen an explosion of educational books, television, and touchscreen applications developed specifically for infants. Although infants interact with these symbolic artifacts on a daily basis, they have difficulty going beyond the symbolic source and transferring learning to real‐world situations. Infants imitate fewer actions and recognize fewer words following demonstrations depicted in picture books and on televisions and touchscreens than they do following face‐to‐face interactions, a phenomenon termed the transfer deficit. Age‐related constraints on memory flexibility contribute to this deficit. Learning can be enhanced when such constraints are considered. Specifically, repeating content and adding visual and auditory cues reduce the transfer deficit. Given the widespread availability of educational media for infants, understanding memory constraints on learning from media has practical implications for the creation and effective use of infant‐directed media in early education.

Effects of Arthro-7&amp;reg; in relieving symptoms of osteoarthritis with mild to moderate arthralgia

Correspondence: Rong Shi School of Public Health, Shanghai Jiao Tong University, 227 South Chang Qing Road, Shanghai 200025, People’s Republic of China Tel +11 86 13 04065 5160 Email shirong61@yahoo.com.cn Background: Osteoarthritis is a common chronic disease affecting aged populations. Conventional therapies tend to result in side effects when used long-term. Arthro-7 (Robinson Pharma, Orange County, CA, USA) has been used by osteoarthritis patients for more than 10 years in the USA and has showed promising effects at relieving osteoarthritis-related symptoms. A previous small, double-blind study has shown some positive effects of Arthro-7 in relieving symptoms of osteoarthritis. The current study was performed specifically in osteoarthritis patients with mild to moderate arthralgia. Methods: A total of 100 subjects over the age of 50 years old who were diagnosed with osteoarthritis and had at least one of the related symptoms were recruited to the study. After primary evaluation, 64 eligible males and females with mild or moderate degrees of arthralgia were randomly assigned 12-week treatment with either Arthro-7 or placebo. The primary outcome measurement was changes in the scores of the related symptoms before and after treatment, using the modified Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 questionnaire. Prior to and at the end of the study, evaluations of symptom scores were recorded. Additionally, self-reported overall changes were recorded at the end of 2, 4, and 8 weeks of treatment and at the end of the study (12 weeks). Results: Arthro-7 improved most symptoms significantly compared with placebo, as indicated by significant reductions in symptom scores. In the Arthro-7 group, 74.5% of the participants reported symptom improvement over the study period versus only 16.3% in the placebo group. Conclusion: In this study, Arthro-7 has shown potent effects in improving and relieving osteoarthritis-related symptoms, particularly joint pain, anchylosis, and difficulty going down stairs.

Autologous Split Peroneus Longus Lateral Ankle Stabilization

Lateral ankle instability is a common clinical entity, and a variety of surgical procedures are available for stabilization after conservative management fails. Herein the authors reviewed outcomes after performing autologous split peroneus longus lateral ankle stabilization, using a previously described surgical technique to anatomically recreate the anterior talofibular and calcaneofibular ligaments. Twenty-five consecutive patients from 2 surgeons’ practices underwent reconstruction between March 2007 and January 2011 with a minimum follow-up of 12 (range 12 to 51) months (mean 29.5 months). Follow-up interviews demonstrated 92.0% good or excellent outcomes with only 8.0% rating the outcome as fair and none as poor; 92.0% had no recurrent sprains or difficulty going up or down hills; 88.0% related no difficulty with uneven ground. The authors conclude that the autologous split peroneus longus lateral ankle stabilization results in a stable ankle with a low rate of complications and high patient satisfaction.

Survey of Psychosocial Problems Facing Breast Cancer Survivors after Undergoing a Mastectomy and Their Awareness of Breast Reconstruction

gone a mastectomy is performed less frequently in Korea than in Western countries. The aim of this study was to investigate the psychosocial problems related to a mastectomy and awareness of reconstruction after a mastectomy in breast cancer survivors. Methods: From March to April 2010, 252 patients who underwent a mastectomy were recruited for this survey. The questionnaire included sociodemographic characteristics of patients, psychosocial problems related to mastectomy, and reasons not to receive breast reconstruction. Results: Patients had difficulty going to a public bath (70.3%) or going to a swimming pool or the beach (74.6%). More than half of patients answered that their physical activity had decreased due to persistent shoulder or arm pain after the mastectomy. The most common psychological problem that patients experienced was distress over the loss of charm as a woman (66.8%), followed by considering themselves disabled (62.0%), and worries about recurrence (59.4 %). The most common reason not to receive a breast reconstruction was the high cost of the operation (59.4%), followed by anxiety about complications (46.7%). Only 16.2% of patients reported that they did not receive enough information about reconstruction from their doctor. Of 229 patients, 43.7% would consider undergoing breast reconstruction in the future. Conclusion: Breast cancer survivors who underwent a mastectomy suffered from various psychosocial problems, and high cost was a major reason for not undergoing breast reconstruction. Broader health insurance coverage should be provided for breast reconstruction in breast cancer survivors.

Sleep problems and workplace injuries in Canada.

To investigate the association between sleep problems and risk of work injuries among Canadian workers and to identify working groups most at risk for injuries. Population-based cross-sectional survey. Canada Participants: Working-age respondents (15-64 years of age) who worked part or full-time in the last 12 months (n = 69,584). None. This study used data from the Canadian Community Health Survey (CCHS) Cycle 1.1 2000-2001. The main indicator of sleep problems was reporting trouble going to sleep or staying asleep. Stratified logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI) for the association of sleep problems and work injury after adjusting for potential confounders and for the survey design. Trouble sleeping most of the time was significantly associated with work injury in both men (OR = 1.25, 95% CI = 1.01-1.55) and women (OR = 1.54, 95% CI = 1.25-1.91). The multivariate stratified analysis found that men in trades and transportation jobs (OR = 1.50, 95% CI = 1.09-2.08), women in processing and manufacturing jobs (OR = 2.46, 95% CI = 1.11-5.47), and women who work rotating shifts (OR = 1.71, 95% CI = 1.11-2.64) were at the highest increased risk for work injury associated with trouble sleeping. Trouble sleeping was associated with an increased risk of work injury. The number of injuries attributable to sleep problems was higher for women compared to men. While most job classes and shift types showed an increased risk of injury, some groups such as women in processing and manufacturing and those who work rotating shifts warrant further investigation and attention for intervention.

Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: the EPIDOS (EPIDemiologie de l’OSteoporose) Study

Background: In elders, decreased muscle mass (sarcopenia) and increased fat mass (obesity) may contribute to difficulties with physical function.Objective: The objective was to examine the association of obesity, sarcopenia, and their combination (sarcopenic-obesity) with self-reported difficulties performing physical function in a cohort of community-dwelling elderly women.Design: We assessed muscle and fat mass by dual-energy X-ray absorptiometry and self-reported difficulties with physical function in 1308 healthy women aged ≥75 y. Sarcopenia was defined as an appendicular skeletal muscle mass ≤2 SD below the mean in a young female reference group. Obesity was defined as a percentage body fat above the 60th percentile. Thirty-six sarcopenic-obese, 90 purely sarcopenic, 435 purely obese, and 747 women with a healthy body composition were studied. Anthropometric measures, health status, lifestyle habits, and self-reported difficulties with 6 different physical functions were obtained.Results: Compared with women with a healthy body composition and after adjustment for confounders, purely sarcopenic women had no increased odds of having difficulties for all of the physical functions assessed, purely obese women had a 44–79% higher odds of having difficulties with most of the physical functions assessed (P < 0.05), and sarcopenic-obese women had a 2.60 higher odds of having difficulty climbing stairs and a 2.35 higher odds of having difficulty going down stairs (all P < 0.05).Conclusions: Sarcopenia is not associated with physical difficulties in the absence of obesity. However, in the presence of obesity, sarcopenia tends to add difficulty for some physical functions.

CBT and hypnosis: the worry‐bug versus the cake

AbstractSleep and pain negatively impact each other. Children in pain often have difficulty going to sleep and sustaining sleep. Anxiety often develops within this negative cycle. Hypnotherapy has been noted as an effective intervention for pain, sleep and anxiety. The case presented illustrates the use of hypnotherapy in contrast to cognitive behavioural therapy (CBT) to resolve an 11‐year‐old girl's cycle of persistent anxiety, abdominal pain and sleep interruption. Utilizing the child's favourite activity of baking a cake, a metaphor for successful sleep was developed. The hypnotherapeutic use of surprise and dissonance promoted a rapid resolution of this pre‐teen's difficulties. An explication of this process is provided. Copyright © 2009 British Society of Experimental &amp; Clinical Hypnosis. Published by John Wiley &amp; Sons, Ltd.

Correlates of Self-Reported Nocturia Among Community-Dwelling Older Adults

Nocturia is a common and bothersome problem with multifactorial etiology. This study examines clinical factors that are associated with nocturia among community-dwelling older adults. A questionnaire-based survey was conducted among a convenience sample of community-dwelling older adults. Nocturia was defined as waking up to urinate two or more times per night for 3 or more days per week. Associations between nocturia status and sleep disturbance, daytime sleepiness, disease burden, and history of falls were determined. Questionnaires were mailed out to 433 participants, and returned questionnaires from 247 individuals (58%) individuals were adequate for analysis. There were 144 women (57%) and 103 men (42%), with mean +/- standard deviation age of 75.1 +/- 6.9 and 76.6 +/- 5.6 years for women and men, respectively. A total of 137 participants (55%) endorsed nocturia, and 57 participants (23%) endorsed nocturia and difficulty going back to sleep. Participants who endorsed nocturia and difficulty going back to sleep were more likely to report poor sleep quality, daytime sleepiness, increased disease burden, one or more falls, and symptoms related to primary sleep disorders. The clinical characteristics of study participants with nocturia and difficulty going back to sleep were different from those with nocturia and no difficulty going back to sleep, suggesting that these two conditions may have different etiological factors and clinical consequences. These findings would have important implications in both clinical and research-related activities aimed at the management of nocturia in older adults.

Adrenocortical carcinoma: a diagnostic and treatment dilemma

A 61-year-old woman was referred by her GP with a 12-month history of weight gain, facial puffiness, difficulty climbing stairs and the tendency to bruise easily. On clinical examination she had a moon face, bruising all over the body and a raised blood pressure of 170/100 mmHg. Routine haematological and biochemical tests were normal apart from a raised glucose level of 16 mmol/litre. 9 am cortisol was raised on three consecutive occasions: 698, 842 and 716 nmol/litre (normal range 119–618 nmol/litre). A simultaneous adrenocorticotropic hormone was undetectable at &lt;5 ng/litre (normal range &lt;50 ng/litre). 24-hour urine cortisol excretion was raised on three consecutive occasions 1643, 2130 and 1918 nmol/24 hours (normal range 33–286 nmol/24 hours). Computed tomography scan of the abdomen and chest revealed a 5 cm mass with heterogeneous enhancement in the right adrenal gland. The liver, both kidneys and spleen were normal and the lung fields were clear. The report stated that the size of the tumour and enhancement characteristics were more in keeping with a malignant rather than benign neoplasm. The patient was commenced on metyrapone and underwent right laparoscopic adrenalectomy. The tumour was removed intact and histopathology revealed features of adrenocortical adenoma with no convincing evidence of malignancy. She made a good clinical and biochemical recovery postoperatively and cortisol levels in the blood and urine returned to normal. Ten months later she developed swellings at the site of entrance of the laparoscope and at the site of the drain. On examination she had 2 cm diameter mobile subcutaneous nodules at three of the port sites. Computed tomography of the abdomen revealed a normal adrenal bed but three subcutaneous masses lying in the right upper quadrant, leading to suspicions of metastasis. The masses were excised and histology confirmed them to be cancerous and morphologically similar to the tumour excised from the adrenals. However, they had acquired more worrying histological features (higher mitotic and apoptotic rate, as well as focal necrosis) and were regarded as being of uncertain malignant potential. The patient made a good recovery from the operation and remained well for the next 2 years with no clinical or biochemical evidence of recurrence of the disease. However, she again developed a puffy face, difficulty going upstairs and her blood pressure became more difficult to control. Her 9am cortisol was raised (679 nmol/litre) with undetectable adrenocorticotropic hormone. 24-hour urine cortisol was raised (2704 nmol/litre), and a computed tomography of the abdomen revealed a 5.4 × 3.6 cm right para-aortic/infrahepatic mass – a 1.1 cm para-aortic lymph node was also noticed. She was commenced on metyrapone and mitotane and referred for debulking surgery. The patient was aware that the surgery would not be curative but would make her Cushing's easier to manage and improve her response to subsequent chemotherapy. She underwent debulking surgery for intra-abdominal metastasis. Part of her right kidney, lymph nodes and appendix were removed. She had hypoadrenalism following debulking surgery. Her mitotane and metyrapone was stopped and she was commenced on high-dose steroid replacement which was gradually tapered off. The patient responded very well to the surgery and her general health improved greatly. Six months after surgery a routine computed tomography scan of the abdomen showed a 2.4 × 2 cm hepatic metastasis. She was referred for surgical ablation but died of a massive cerebral haemorrhage.

Abstract 5908: Prognostic Significance of Poor Sleep Quality in Patients Referred to a Heart Failure Clinic

PURPOSE To assess whether poor sleep quality carries prognostic significance for patients with suspected heart failure (HF). METHODS Data from patients referred to a HF clinic between July 2001 and October 2006 was analysed in a Cox Regression model to assess the prognostic significance of sleep quality. Patient responses for 3 questions addressing sleep quality (difficulty going to sleep, waking up in the night, and lack of refreshing sleep) were used to generate a sleep quality score (SQS) of 1 (none or minimal sleep impairment, N= 1054); 2 (mild to moderate sleep impairment, N= 908); or 3 (severe sleep impairment, N= 644). RESULTS Of 2606 patients, 59% were male. Median age was 72 yrs (Interquartile range (IQR) 65–78). There were 549 deaths during a median follow up of 37.5 months (IQR 26–46.4). Kaplan Meier survival curves showed that SQS 3 was associated with significantly worse prognosis (Figure 1 ), and this association persisted despite correction for age, sex, NYHA class, severity of LV systolic dysfunction, BMI, pulse pressure, lab parameters (sodium, creatinine, haemoglobin, NTproBNP, CRP and cholesterol), medication use (loop diuretics, ACE inhibitors, beta-blockers, statins and aldosterone antagonists) and comorbidities (diabetes, hypertension, AF, IHD, COPD and CVA)(Table 1 ). CONCLUSION Poor sleep quality is an independent prognostic marker in patients referred to a HF clinic. Cox Regression Analysis: Significant prognostic indicators

Circadian rhythmicity and the pharmacologic management of insomnia.

The circadian clock modulates timing of sleep and wakefulness. In certain situations, the circadian potentiation of wakefulness may interfere with desired sleep-scheduling, particularly in the elderly and shift workers. Known abnormalities of circadian regulation are defined by their impact on sleep-wake state expression. In delayed sleep phase syndrome, patients have trouble going to sleep and arising at reasonable hours and are alert in the evening and sleepy in the morning. Patients with advanced sleep phase syndrome are sleepy in the evening and awaken very early and alert in the morning. In shift-work sleep disorder, individuals attempt to wake and sleep out of phase with the circadian clock. As with jet lag, the clock is functioning normally, but the requirements on the clock are abnormal. Typical insomnia can also be associated with circadian rhythm alterations. Practice guidelines and clinical studies data are needed to lead appropriate therapy selection and effective management.

Adverse Associations of Sleep Problems in Australian Preschoolers: National Population Study

In contrast to school-aged children, the impact of sleep problems in preschool-aged children is not well documented. We aimed to determine relationships between preschool-aged child sleep problems and child behavior; health-related quality of life; verbal, preliteracy, and early numeracy skills; diagnosis of attention-deficit/hyperactivity disorder; and injury. Participants included families (n = 4983) participating in the first wave of the Longitudinal Study of Australian Children, a nationally representative study of Australian children aged 4 to 5 years surveyed from March to November 2004. Measures consisted of a primary caregiver's report of whether their child had a sleep problem (none versus mild versus moderate/severe); specific sleep patterns occurring > or = 4 nights per week; health-related quality of life (by using the Pediatric Quality of Life Inventory 4.0); behavior (by using the Strengths and Difficulties Questionnaire) and parent-reported diagnosis of attention-deficit/hyperactivity disorder; and injury requiring medical attention in the past 12 months. Tests of receptive vocabulary and preliteracy/numeracy skills (by using the Who Am I? developmental assessment and the adapted Peabody Picture Vocabulary Test, 3rd Edition) were directly administered to each child. Sleep problems were common, and compared with children without sleep problems, children with sleep problems had poorer child health-related quality of life, more behavior problems, and higher rates of attention-deficit/hyperactivity disorder. Difficulty going to sleep and morning tiredness had greater adverse associations than snoring or night waking. Given that sleep problems are very common, the adverse outcomes shown here could affect the transition to school for a very large number of preschoolers.

Comparison of fluticasone propionate aqueous nasal spray and oral montelukast for the treatment of seasonal allergic rhinitis symptoms

Few studies have directly compared the efficacy of intranasal corticosteroids with that of leukotriene receptor antagonists for the treatment of daytime and nighttime symptoms of seasonal allergic rhinitis (SAR). To compare fluticasone propionate aqueous nasal spray, 200 microg daily, with oral montelukast, 10 mg daily, for the relief of SAR symptoms. Patients with SAR 15 years or older were randomized to receive either fluticasone propionate (n = 367) or montelukast (n = 369) in this double-blind, double-dummy, parallel-group study. The primary efficacy measure was the mean change from baseline in daytime total nasal symptom scores (TNSSs) (the sum of 4 daytime individual nasal symptom scores [INSSs] assessing nasal congestion, itching, rhinorrhea, and sneezing), averaged across weeks 1 and 2. Secondary efficacy measures included the 4 daytime INSSs, nighttime TNSSs (the sum of 3 nighttime INSSs assessing congestion on awakening, difficulty going to sleep, and nighttime awakenings), and the 3 nighttime INSSs averaged across weeks 1 and 2. Mean changes from baseline in daytime TNSSs (P < .001), all daytime INSSs (P < .001), nighttime TNSSs (P < .001), and all nighttime INSSs (P < or = .02) showed significant differences favoring fluticasone propionate over montelukast across 2 weeks of treatment. Compared with montelukast, fluticasone propionate provided significantly greater improvement in daytime and nighttime SAR symptoms.

Validation of the nighttime symptoms score as a clinically relevant measure of allergic rhinitis

The aim of this study was to validate the nighttime symptoms score (NSS), which incorporates individual scores for difficulty going to sleep and nighttime awakening caused by nasal symptoms and nasal congestion on awakening, as a clinically relevant measure of allergic rhinitis (AR). Fifty-five general season AR (SAR) symptom items were generated by interviews with 14 patients with symptomatic SAR without concomitant asthma for use in an Importance Rating Questionnaire (IRQ). A second group of patients (n = 83) with symptomatic AR without asthma rated the importance of each item on the IRQ. Correlation coefficients were calculated to examine the relationships between the six sleep quality questions on the IRQ and the other AR symptoms and between the symptom questions of the NSS, the Daytime Nasal Symptoms Score (DNSS), and the individual domains of the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ). The majority (94%) of patients with active AR reported some degree of symptoms relating to sleep quality. The six sleep quality items on the IRQ were selected by 71-84% of patients. The sleep quality items were more highly correlated with each other (r = 0.48-0.85) than with the four items of the DNSS (r = 0.01-0.42). There was a moderate-to-strong correlation of the RQLQ sleep domain with the two sleep questions of the NSS (r = 0.44-0.57). The individual symptom questions of the NSS and the DNSS were only moderately correlated with each other. Sleep quality questions measure aspects of SAR that are not captured by daytime SAR symptoms. The results show that the NSS is a valid and relevant clinical measure of the impact of nighttime sleep disturbance on AR patients.